Rachel Lee M.S. CCC-SLP, CLC, CIMC & Nicole Haney M.S. OTR/L, CIMC | April 25, 2024 | Speech Therapy

All Tied Up: Lip & Tongue Ties from Professional and Personal Perspectives

In response to a headlining article published by the New York Times titled, “Inside the Booming Business of Cutting Baby's Tongues”

Hey there! We are pediatric occupational and speech therapists who specialize in tethered oral tissues, feeding, lactation, and infant massage. We are also mothers who have experienced feeding difficulties due to tethered oral tissues with our children. The recent New York Times article discussed lip and tongue ties as a trend, causing fear-mongering with the most severe outcomes and monetizing procedures. It is important to take into consideration the facts from trained medical professionals who specialize in this area, as this can continue gaslighting mothers who are attempting to advocate for their children in times of distress. We are here to untie the knot. 

What are preferred providers? 

Preferred providers consist of a team approach. This team will assess oral function, feeding, swallowing, speech sound disorders, and muscular tension. Pre-op care is crucial in order to rule out alternate factors including reducing fascial restrictions, training caregivers, avoiding oral aversions, and establishing clinical baselines (Walsh, 2023). The following are considered preferred providers as a part of the multidisciplinary team.

  • Medical provider- Pediatric dentist, ENT 

  • Feeding team- Lactation consultant (IBCLC), speech therapist (ST), and/or occupational therapist (OT). (Must be well versed in ties, oral motor, and/or myofunctional therapy)

  • Body work- Chiropractor, physical therapist (PT) and/or craniosacral therapist (CST)

What is structure vs. function?

It is critical to not only look at structure (frenulum or the “string” under your tongue) when diagnosing tongue ties. Function must be assessed in order to make a differential diagnosis. For example, how is the structure functioning in the presence of tight tissue impacting feeding, speech, body tension, breathing, sleep, etc? The structure must have a negative impact on function to warrant a diagnosis (Bulkin, 2023). This is typically first noticed in infancy; however can later be identified in children, adolescence, or adulthood.

  • Ex: colic, gas, hiccups, reflux/GERD, constipation, poor latch, lack of weight gain, extended feedings, gagging, clicking during feedings, open mouth posture, high narrow palate, picky eating, grazing, snoring, bed wetting, bruxism, sleep disorders, hyperactivity, poor speech intelligibility.

In an excerpt from Dr. Richard Baxter’s response to the NYT’s article, 

“The babies who don’t get treatment sadly do not outgrow a restricted tongue but can often (not always) have issues with speech, eating, sleep, and more. The confounding factor is that not all tongue-tied patients have speech or breastfeeding difficulties, just like not every patient who had COVID ended up in the ICU or had significant symptoms. A restricted tongue causes different symptoms for each individual baby, so an individualized and team approach involving therapists of various disciplines is critical to proper diagnosis and treatment” (Baxter, 2023). 

What is pre-op care?

This pre-procedure therapy accomplishes many objectives: “It allows the professional to assist in preparation for the procedure (what to expect, common troubleshooting issues, red flags, etc). If you think about knee replacement surgery, we want a strong calf and a strong hip to support that new structure.  Same with tongue tie release.  We want to work on the jaw, lips, cheeks, etc.  Think about who heals better: An Olympic athlete or someone who does no physical activity?  We want to work to tone, strengthen, coordinate, and sequence patterns while inhibiting compensations prior to a procedure”   (Henning, 2019). 

Rushing a release can lead to suboptimal outcomes and it’s critical to wait for the optimal timing of release per your providers’ recommendations and child’s readiness. The body needs to be properly prepped: including a full-function oral motor assessment combining desensitization for oral aversion, decreasing tension patterns or discomfort, and regulating the nervous system.

How long does it take to heal?

Healing is described in phases:

  • Days 1-4: Inflammatory phase

  • Days 4-20: Proliferation fibroblastic phase

  • Days 20+: Maturation remodeling phase

“Due to wound healing principles, any wound left open post-procedure will try to contract and stabilize by reattaching. It is highly important for patients/parents to be instructed on active wound management techniques. The time to learn this is prior to the procedure for the best success” (Henning, 2019). 

Many families report a positive change in symptoms immediately after a release, however, continued improvements are observed after completion of post-op therapy to retrain the orofacial muscles on how to function with their new range of motion.

“The goal is to gain and/or restore optimal function so you or your child can thrive” (Bulkin, 2023). As healing continues and skills increase, you may notice: Quiet nasal breathing, closed mouth posture with lingual palatal suction, improved sleep, infants who are content with decreased colic-like symptoms, quicker feeds, weight gain in infants, less grazing in children, increased speech intelligibility, decreased gagging/choking, and reduced hiccups, reflux, and constipation.

What is your personal experience?

Rachel’s experience

I decided in my pregnancy that I wanted to breastfeed for as long as possible with a personal goal of 1 year. I decided that I wasn’t going to check for ties until I noticed signs. I wanted an unbiased opinion so I could relate to my families at work on a more personal level. Unfortunately, these signs came earlier than anticipated. My son immediately demonstrated difficulties latching, regardless of position. I’ll never forget the overwhelming emotions I experienced- I felt anxious, defeated, like a failure, or at fault. I began hand-expressing colostrum and syringe feeding until he could latch successfully. I received lactation support in the hospital (it is difficult to be a mom and therapist), however the possibility of ties was never discussed. We finally got a latch, and although it was shallow and painful, we powered through. He was 7lbs 7oz at birth and 7lbs 1oz at discharge. My anxiety then quickly transformed into concern. After a few days at home, I started experiencing significant discomfort including nipple trauma, painful latch, and vasospasms. I remember holding my breath, clenching my toes, and dreading each feeding. At this point, I knew there were ties and it was time to check. Sure enough, my son had upper and lower lip ties, buccal or “cheek” ties, and a tongue tie. I got established with an IBCLC, CST, and chiropractor. My team addressed compensatory patterns, strengthened oral motor skills, and released body tension. Once therapeutic readiness was identified, we scheduled with a pediatric dentist for releases at 3 weeks of age. My son latched right after his procedure. The pain had diminished and he was transferring more volume at the breast. It was amazing the difference- even I couldn’t believe the change! We continued seeing our team to ensure appropriate wound healing and retraining of orofacial muscles. Now, my son is 1 year old and we are still breastfeeding. I am forever grateful for this team who helped us navigate through this feeding journey and supported us along the way. Advocate! Breastfeeding shouldn’t be painful and reaching your feeding goal is possible.

Nicole’s experience:

Sitting in the hospital bed after my baby was born, I remember thinking when latching my son for the first time “ Am I doing this right?”.  I was a first-time mom. The overwhelming emotions of welcoming a child into the world, doctors and nurses in and out of my room, and my body aching from delivery heightened all my sensations. I made sure to check with lactation several times in the hospital to ensure our breastfeeding journey would be successful. Our first night home, my son cried the ENTIRE night. He nursed all night and wasn’t satisfied. His latch was completely shallow. I immediately knew something was off and made an appointment that week to meet with lactation from the hospital. At our appointment, she agreed his latch was very shallow and he was not transferring enough ounces to feel satisfied. She suspected ties and recommended seeing a speech therapist who specializes in feeding. My son was colicky, gassy, had horrible hiccups, constantly fell asleep at the breast, and had a poor latch with the bottle. We tackled triple feedings via breast, bottle feeding, and pumping around the clock every 2 hours. Sure enough, when our appointment arrived, we discovered he had a tongue and lip tie. I made sure to set up the necessary steps for pre-care therapy including a chiropractor, physical therapist, and speech therapist. My son had his release by a pediatric dentist at 3 weeks of age and we continued to work with our team for post-care and body tension.  At 6 weeks old, I made the decision to change course from breastfeeding to exclusively pumping and bottle feeding until my son was 12 months old. He is now a healthy thriving 5 year old! After my son was born, I knew what signs and symptoms to look for. I delivered a daughter 22 months later and my third child, another son, two years after her. Both of which had difficult feeding journeys after birth. Both of these two would latch at the breast; however, struggled to gain weight, were colicky, gassy, did not sleep well, and required triple feedings. With my two youngest children, we moved to Kentucky from a different state. Knowing the process, I scheduled appointments with a team of providers for consultations. Both my daughter and youngest son were diagnosed with bilateral buccal, tongue, and lip ties. We set up care with an IBCLC, CST, chiropractor, and speech therapist. My daughter had her release by a pediatric dentist at 6 weeks old and my youngest son had his release at 5 weeks old. With these two, I made a personal goal to try to breastfeed as long as I could. I wanted to try again after my first! I successfully breastfed both my now 4-year-old daughter, and 2-year-old son for 14 months each. My experience as a mother of three with feeding difficulties has inspired me to educate families on the benefits of therapy and establishing success for functional feeding. Let us be a part of your team!

Where can I learn more? 

In efforts to discontinue the spread of medical misinformation, here are some helpful resources. Families deserve to thrive! 

Works Cited

Helping your family build skills for life is our priority. Schedule an evaluation with one of our expert therapists if you have concerns about your child or want more information about the topic of tethered oral tissues!